Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions

The Agency for Healthcare Research and Quality supports research on the quality and safety of the hospital discharge process and care transitions. Improvements in these areas can lead to reductions in potentially avoidable readmissions. This page features links to AHRQ's resources and tools - based on this research - for clinicians, patients, and researchers.

Discharge

• Re-Engineered Discharge (RED) Toolkit
  • Materials Related to RED:
    • Taking Care of Myself: A Guide for When I Leave the Hospital
      • Impact Case Study: Sutter Center for Integrated Care Using AHRQ Guide in Patient Materials
      • Pennsylvania Psychiatric Institute Slashes Readmission Rates With AHRQ-Based Discharge Program
      • Penn Medicine Chester County Hospital Implements AHRQ Toolkit To Reduce Readmissions
      • AHRQ's RED Toolkit Helps Lower Readmissions in Dignity Health Hospitals
      • Memorial Hospital Uses AHRQ Resources To Cut Readmissions, Promote Patient Self-Management
      • AHRQ's RED Toolkit Inspires Improved Patient Discharge at Nacogdoches Memorial Hospital
      • AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals
      • AHRQ PSNet Article: Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes
      • AHRQ PSNet Perspective: Patient Safety During Hospital Discharge
      • AHRQ PSNet Perspective: Post-Hospital Syndrome, In Conversation With Harlan Krumholz
      • AHRQ PSNet Web M&M Cases and Commentaries: Discharging Our Responsibility
      • AHRQ PSNet Web M&M Cases and Commentaries: Postdischarge Follow-Up Phone Call

      Readmissions

      • Primary Care-Based Efforts To Reduce Potentially Preventable Readmissions
      • Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions
      • Healthcare Cost and Utilization Project (HCUP) Materials:
        • HCUP Nationwide Readmissions Database (NRD)
        • HCUP Statistical Briefs - Readmissions and Revisits
        • AHRQ PSNet article: Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge
        • AHRQ PS Net Primer: Readmissions and Adverse Events After Discharge

        Transitions of Care

        • Project BOOST (Better Outcomes for Older Adults through Safer Transitions) Toolkit
        • I-PASS Tool
        • Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit
        • Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
        • MATCH Toolkit Impact Case Studies:
          • Georgia Hospitals Improve Medication Reconciliation Process With AHRQ Toolkit
          • Two Indiana Facilities Use AHRQ Toolkit To Revise Medication Reconciliation
          • Four Kentucky Hospitals Use AHRQ Toolkit To Improve Medication Reconciliation
          • Maryland Hospitals Revise Medication Reconciliation Process With AHRQ Toolkit
          • Massachusetts Hospital Improves Medication Reconciliation With AHRQ Toolkit
          • Michigan Providers Improve Medication Reconciliation Process With AHRQ Toolkit
          • Missouri Hospitals Improve Medication Reconciliation Process Using AHRQ Toolkit (KT-CQUIPS-93)
          • Four Missouri Hospitals Use AHRQ Toolkit To Improve Medication Reconciliation (KT-CQUIPS-80)
          • Five Nebraska Hospitals Use AHRQ Toolkit To Improve Medication Reconciliation Across Care Settings
          • Six New Jersey Hospitals Reduce Adverse Events With AHRQ Medication Reconciliation Toolkit (KT-CQUIPS-85)
          • Four New York Providers Use AHRQ Medication Reconciliation Toolkit To Improve Care
          • Six Texas Hospitals Improve Care With AHRQ Medication Reconciliation Toolkit
          • AHRQ PsNet Article: Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists
          • AHRQ PSNet Primer: Handoffs and Signouts
          • AHRQ PSNet Perspective: Handoffs and Transitions
          • AHRQ PSNet Perspective: Transitions in Care, In Conversation With Eric Coleman
          • AHRQ PSNet Primer: Discharge Planning and Transitions of Care

          Related Patient Safety and Quality Resources and Tools

          Cross-Cutting Issues

          • PSNet Primers:
            • AHRQ PSNet Primer: Checklists
            • AHRQ PSNet Primer: Communication Between Clinicians
            • AHRQ PSNet Primer: Improving Patient Safety and Team Communication Through Daily Huddles
            • AHRQ PSNet Primer: Medication Errors and Adverse Drug Events
            • AHRQ PSNet Primer: Medication Reconciliation
            • AHRQ PSNet Perspective: Patient Safety in the Physician Office Setting
            • AHRQ PSNet Primer: Teamwork Training
            • St. Joseph’s Hospital Improves Patient Safety Using AHRQ Tools

            Health Literacy

            • AHRQ Health Literacy Resources and Tools
            • AHRQ Health Literacy Universal Precautions Toolkit
            • AHRQ PSNet Primer: Health Literacy

            Patient and Family Engagement

            • AHRQ PSNet Primer: Patient Engagement and Safety
            • AHRQ Engaging Patients and Families Resources and Tools
            • Guide to Patient and Family Engagement in Hospital Quality and Safety
            • Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
            • Questions Are The Answer
            • QuestionBuilder App